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Missouri's recovery experience

November 1, 2007
by Joseph Parks, MD
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The Show-Me State liked the results of its Procovery pilot so much that it is implementing the program statewide

One can believe in recovery principles and the clinical and humanistic value of person-centered care yet find that implementing recovery primarily through policies of humanistic intention fail to change workforce and community behavior or transform systems. As a report on implementing recovery in behavioral healthcare notes:

Without any infrastructure for recovery-based mental health care, it's no wonder that so many administrators and clinicians haven't bought in to what is essentially a basic human right to feel better. In fact, just mentioning the word recovery seems to cause a stir depending on your training, beliefs, and role in the mental health rehabilitation system.1

In the course of implementing a recovery model in the Missouri Comprehensive Psychiatric System, we have identified certain components essential in our own recovery implementation. The Missouri Department of Mental Health decided to adopt a specific recovery model as foundational to service delivery and ultimately to system transformation. In 2005, the department selected the Procovery program developed by Kathleen Crowley2 as the recovery model for an urban-rural demonstration program in the St. Louis and Southeast Missouri regions.

Procovery is a reference to focusing on forward potential, versus traditional, common understandings of recovery as focusing on regaining a prior state of health. The program emphasizes a hope-centered, forward-focused, and skills-based partnership among the client, family, service provider, and community. The Procovery program includes 8 principles for resilience in healing and 12 strategies for action. It uses a highly structured system for group training and support, the Procovery Circle, across target populations and across diverse service settings.

While we initially were considering 8 to 12 Circles, the pilot rapidly grew to accommodate demand across stakeholders, settings, and regions (both urban and rural). In the end, 1,075 people (treatment professionals, people living with mental illness, family members, and community members) attended voluntary full-day core trainings. By the pilot's completion more than 80 Procovery Circles were active across different settings. From June 2005 to May 2007, more than 3,750 Procovery Circle meetings were held with an average attendance of 8.6 people. Due to the popularity and success of the demonstration pilot, in June we announced that Missouri will launch statewide implementation of recovery services through the Procovery program.

The Missouri Institute of Mental Health's evaluation of the pilot noted:

Most important, it can be concluded from the evaluation of the Missouri Procovery Demonstration Program that Procovery is a promising catalyst of system transformation. The success of Procovery Circles to instill hope and a forward focus among mental health consumer members means that statewide implementation of this program could facilitate progress towards an integrated system response to growing demands from consumers for recovery-based services and supports to secure jobs, housing, and training.3

Particular Procovery components that have been shown to be essential include the following.

Specificity. Strengths-based attitudinal principles of hope must be accompanied by concrete, practical, actionable skills across the range of wellness self-management and decision making to support and drive desired behavioral change.

Application across diagnoses, including behavioral and physical. Data from several states have shown that people with serious mental illness served by public mental health systems die on average at least 25 years earlier than the general population.4 Recovery and person-centered care programming can and must serve as a point of integration for individuals with co-occurring addictions, traumas, and physical diagnoses.

Staff training. Recovery often is viewed solely in terms of how individuals support their own healing, but a recovery system must create a common dialogue and skill set for staff and a common view of what is possible for staff and those they serve as they work together. A unified set of principles and skills that apply equally to the workforce and an effective training model are essential to institutionalizing recovery, and are equally valuable for supporting staff members who themselves often face stress, isolation, and burnout from long years of challenging human service.

Application across a spectrum of settings, cultures, and stakeholders. Recovery principles, skills, and the implementation structure must resonate in urban and rural settings and be a vehicle for building cultural competence.

Fidelity and accountability. In institutionalizing a program across diverse stakeholders, agencies, and settings, we must not just ask providers to implement programs. We must also provide tools to enable them to ensure fidelity and, ultimately, accountability to those they are seeking to serve.

Complementary, not competitive, to existing services and programs. Rather than seeking to replace or compete, recovery programming should support and strengthen existing agencies and providers. Adoption based on consumer demand rather than regulation operates at significantly higher speed and impact.